Provider Demographics
NPI:1952568552
Name:POLK, JONATHAN DANIEL (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:DANIEL
Last Name:POLK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4800 NE STALLINGS DR STE 114
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-1250
Mailing Address - Country:US
Mailing Address - Phone:936-569-0680
Mailing Address - Fax:936-205-4130
Practice Address - Street 1:4800 NE STALLINGS DR STE 114
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-1250
Practice Address - Country:US
Practice Address - Phone:936-569-0680
Practice Address - Fax:936-205-4130
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-21
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN0372208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery